In the recently published proposed rule related to the CY 2018 Hospital Outpatient Prospective Payment System (OPPS), the Centers for Medicare & Medicaid Services (CMS) announced that it is considering changes to the regulation governing the date of service (DOS) for clinical laboratory and pathology specimens.  The DOS rules are important to laboratories and hospitals because they dictate which party must bill Medicare for certain laboratory testing performed on stored specimens collected during a hospital procedure but ordered after the patient has left the hospital.  If revisions are ultimately finalized, the proposal could have significant business implications for independent laboratories and hospitals.

Continue Reading CMS May Decide to Permit Labs to Bill for Certain Tests Provided to Outpatients

Written by: Karen Lovitch and Lauren Moldawer*

As part of the Outpatient Prospective Payment System (OPPS) Rule issued last week, the Centers for Medicare & Medicaid Services (CMS) finalized its proposal to conditionally package certain ancillary services assigned to APCs with a “geographic mean cost” of $100 or less.  This change, which will take effect on January 1, 2015, will apply to the technical component of most anatomic pathology services.  Because the hospital’s payment for the primary procedure will cover these services, the hospital may no longer bill for them separately.  But physicians can continue to seek reimbursement under the Medicare Physician Fee Schedule for the professional component of the service. Continue Reading CMS Finalizes OPPS Rule Packaging Pathology Services Ordered for Hospital Outpatients

Written by: Andrew J. Shin

Citing the need to complement a portfolio of pilot projects that focus mostly on primary care and the inpatient setting, CMS released a Request for Information (RFI) on February 11th, seeking input on potential payment and care delivery models that focus on outpatient specialty care and complex/chronic disease management care.  As compared to the initiatives currently underway through the Center for Medicare and Medicaid Innovation (CMMI), this latest RFI has the potential to impact a broader group of health care stakeholders, such as drug manufacturers, diagnostic companies, laboratories, and a variety of physician specialty providers ranging from anesthesiology to radiology.

The new pilots embedded in the latest RFI will address outpatient procedures and chronic disease management. Continue Reading CMS Expands Payment Reform to Outpatient Care in New RFI